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Questions marked with a * are required
PURPOSE OF PEER LISTENING
Peer Listening is an opportunity to clarify and strengthen academic, personal, and wellness goals with an empathetic, trained peer. Peer Listeners will review this form prior to your meeting in order to help them prepare information and resources. 

LIMITATIONS OF PEER LISTENING
Peer Listening is not therapy and is not a substitute for mental health counseling or treatment, medical treatment, or consultation with a licensed mental health or medical provider. Peer Listeners do not provide any type of health treatment to students. 

Peer Listening should not be used for crisis support. If you are feeling unsafe or have a mental health concern, call the Mines Counseling Center (303-273-3000), Suicide Prevention Hotline (988), or Colorado Crisis Services (1-844-493-8255) instead of using this form.

PRIVACY
Peer Listeners are current Peer Educators at the Colorado School of Mines who go through an in-depth, additional training as part of Mines Betsy's Friends Peer Educator Program. The Student Wellness Promotion, Counseling Center, and Sexual Harassment and Assault Advocacy, Prevention and Education (SHAPE) offices maintain the privacy and security of all personally identifiable information (PII) consistent with state and federal laws, regulations, and policies. All personnel in these offices, including Peer Listeners, are required to protect the privacy of PII from unauthorized access, use, or disclosure per the Colorado School of Mines policy.  All PII contained in student education records is protected by the Family Education Rights and Privacy Act (FERPA).  All Student Wellness Promotion, Counseling Center, and SHAPE personnel, including student employees, are required to complete and sign Confidentiality Agreements upon hire or prior to participation in Mines activities. The Confidentiality Agreement describes expectations and responsibilities regarding the privacy requirements for confidential information. 

Peer Listeners do not discuss any personal information from the coaching sessions with anyone other than Student Wellness Promotion, Counseling Center, and SHAPE professional staff advisors. Professional staff advisors are classified as “Responsible Employees” and therefore are required to report if they hear that someone may be in danger or about situations of intimate partner violence, stalking, protected-class discrimination or harassment, or sexual misconduct.

Peer Listening is a FREE service (no cost) for Mines students. 

Unless virtual options are arranged, meetings will take place on campus and will be 30 to 45 minutes. An Outlook calendar invite with the time, location, and the Peer Listener you are meeting with will be sent to you within 5 to 7 business days after you submit this form.

If you have any questions about Peer Listening, please email peereducation@mines.edu. 
Name (first and last)
Campus-Wide ID (CWID) #
Mines Email Address
Year in School
What personal or academic topics/goals would you like to discuss with a Peer Listener? 
Which Peer Listener(s) would you prefer to meet with?
Please select all times you are available to meet with a Peer Listener. Meetings will take place on campus and will be 30 to 45 minutes. An Outlook calendar invite with the time, location, and the Peer Listener you are meeting with will be sent to you within 5 to 7 business days after you submit this form. 
9–10 AM
10–11 AM
12–1 PM
1–2 PM
2–3 PM
3–4 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Please select all on-campus locations you are able to meet with a Peer Listener. Meetings will take place on campus and will be 30 to 45 minutes. An Outlook calendar invite with the time, location, and the Peer Listener you are meeting with will be sent to you within 5 to 7 business days after you submit this form. 
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